Page 45 - 59peadiatric-surgery-speciality8-14_opt

84 Psychological Issues in Paediatric Surgery

and its management can be prohibitive. The cost is borne solely by gender preference is based on the roles of sons in farming, trading,
the parents or guardians of the child. Many of these parents are living giving support in old age, and providing proper burial rites. In some
below the poverty line; thus, having the added stress of how to fund instances, this desire for a male child has led to marital breakdown and
the surgery and purchase the needed postsurgical management for the divorce or marriage to a second wife, so in an attempt to have a male
37
child may be an overbearing burden. Ameh et al. have pointed out child, a woman ends up having ten or more children, which increases
45
that the inability of parents to carry the financial burden has led to their the chance of having malformed babies.
removing the child from the hospital prior to completion of postsurgi- In this climate, the male child’s health takes on additional
cal management. Coupled with this is the difficulty that often arises psychological meaning for the parents, and his welfare plays a very
when trying to access blood products or antibiotics that are needed for prominent role in the family’s functioning. The high expectations that
the child. These are all implicated in the development of postsurgical arise from this lead to increased preoperative anxiety for the parents
complications. Having health insurance would help to reduce this cost, and, depending on the age of the child, may bring additional emotional
but not many of these countries offer insurance, and for others, such guilt in considering what the parents may be going through as a result
as Nigeria, it is still in its infancy and not accessible for most children of his condition. This may be both in terms of financial sacrifices that
presenting for surgical diagnoses. the parents are making for this procedure and the possible ridicule and
Accessibility of Surgical Services discrimination that the family on the whole may be experiencing.
There are only a few qualified paediatric surgeons in sub-Saharan Discrimination and Stigmatisation
Africa, and for most part these surgeons work in tertiary health care In situations where the expectations are high, so also is the pressure to
institutions located in urban town centres. Many of these facilities have children and the possible discrimination that can arise as a result
are not adequately funded and many are outdated. The additional and of this. A woman with children is accorded respect; a woman who does
38
almost nonexistent primary and secondary health care system is weak. not have children is at a higher risk of being disrespected or excluded
The 2003 data for Nigeria, for instance, shows the ratio of paediatric at certain social forums. She is often ridiculed and jeered by her mates
surgeons to a child as 1 surgeon for every 2.2–2.7 million children. This for not having children and sometimes specifically for not having a
ratio varies greatly across the regions of the country with more of the male child.
surgeons being located in the southern, more affluent area. There is an added complication for children born with some
This picture is reflective of most other sub-Saharan countries. By medical condition that may require surgery, either corrective or due to
implication, many hospitals in these countries do not have a resident events occurring in early childhood, that may lead to the child being
paediatric surgeon; in these instances, paediatric surgical cases are disfigured. In the traditional setting, any person that does not meet the
handled by general practitioners, who are more competent in dealing norm and cannot play along with other children for medical or other
with adult patients and often with equipment that is meant for reasons is teased, challenged, made fun of, ridiculed, and generally
adult surgical procedures. Gaps currently exist in postoperative pain isolated or stigmatised. 46–48 These children, by reason of their condition,
management for adults, so by implication this is even more so for pain are likely to be competitively denied basic needs of appropriate
management in children. 39 clothing, good feeding, sound education, and emotional support. This
Parents are often aware of the shortage of personnel and associated discrimination and stigmatisation may be generalised to the whole
issues and their implications for their child’s successful surgical family, so the child’s siblings are teased and spoken of in derogatory
operation. Additionally, in this climate, where services are scarce, terms. This leads to fear and anxiety for both parents and children,
getting the desired treatment often implies relocating with the child, at even more so when a surgical procedure alters in some way the child’s
least temporarily, to the towns where the hospitals are situated. This, as functioning or physique. There is the fear of how the child will recover
earlier pointed out, has cost implications that are borne by the parents. and adjust to the fact of not being able to move around. Thus, having
The absence of funds or inability to access these facilities leads to to undergo an invasive procedure in any of these conditions is met with
added stress for the parents and child. great anxiety and anticipation.
Meaning and Essence of Children in the The discrimination experience and the treatment of children with
49
Sub-Saharan Cultures disabilities are due to ignorance, superstition, and taboos. This may
In many of the sub-Saharan countries, great value is place on having be the result of cultural beliefs that attribute the cause of the disability
children; in the more traditional settings, the norm was to have many either to a warning curse from God, family sins, offences against the
children. For instance, the ideal family size in a Yoruba monogamous gods, witches or wizards, adultery, misfortune, ancestors, a misdeed in a
50
marriage is five to eight living children. Economic factors affecting previous life, an evil spirit, or the killing of certain forbidden animals.
family income and ability to cater for large families, as well as con- In certain situations, it is not so much the illness as it is the particular
flicts leading to relocation of families, has affected the desired num- invasive approach or associated issues that lead to the heightened
46
ber of children per household. In some countries in the sub-Saharan level of stigma that is experienced. Archibong and Idika, in their
region, smaller family size is the norm. Even though there is reduction prospective study between 1992 and 2001 of treatment for anorectal
in the number of children per household in some of these countries, malformations in a tertiary referral centre in South-Eastern Nigeria,
Woldemicael has pointed out that children are still greatly valued. The found cultural beliefs implicated in the loss of 11 (20%) of their surgical
40
value assigned to children also has a bearing on the economic benefits cases. A common procedure for treatment of anorectal malformation is
that they bring to the family. They are seen as additional sources of for the child to undergo an initial colostomy. This process allows for
income, and increase the likelihood that one would be successful, thus adequate weight gain, reduces possible postoperative complications,
bringing honour to the family. The pressure to have a child in these and increases the success of perineal abdominal pull-through. The
countries is thus enormous, and the health and status of the child takes authors, however, found that the practice of wearing a colostomy bag
on different meanings and makes any illness or need for surgery of was detested by some families and that it was considered by society to
particular concern for the parents or guardians. be a bad omen and therefore stigmatised. They believed that the deaths
This bias becomes even more pertinent, depending on the gender of the 11 children in the course of treatment were due largely to neglect
of the child. Across the sub-Saharan region, there is a preference for a of the child by family members, fuelled by the superstitious beliefs and
male child; a male child is considered a major asset to the parents for negative attitudes.
both social and economic reasons. 41-43 Hake has pointed out that this Also, due to the condition and how it is viewed by the parents or
44
society, children may be brought to the hospital late or be removed